Community Health Nurse Educators and Disaster Nursing

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Community Health Nurse Educators and Disaster Nursing Community Health Nurse Educators and Disaster Nursing

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Jody Spiess University of Missouri-St. Louis, [email protected]

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Running head: Disaster Nursing Education 1

Community Health Nurse Educators and Disaster Nursing Education

Jody A. Spiess

MSN, Masters of Science in Nursing, Webster University, 2011

BSN, Bachelors of Science in Nursing, Webster University, 2007

A Dissertation Submitted to The Graduate School at the University of Missouri-St. Louis

in partial fulfillment of the requirements for the degree

Doctor of Philosophy in Nursing

December 2020

Advisory Committee

Committee Chairperson, Ph.D.

Dr. Umit Tokac

Committee Faculty Member 2, Ph.D.

Dr. Annah Bender


Dr. Roxanne Vandermause


Dr. Mary Ann Drake

Copyright, Jody A. Spiess, 2020

Disaster Nursing Education 2

Acknowledgments

I wish to dedicate my dissertation to Dr. Mary Ann Drake who has selfishly given so

much of herself to educate and mentor me over the years. Dr. Drake is the kind of

educator who not only teaches, but inspires. Thank you for introducing me to the

beautiful world of public health and for instilling a passion for social justice in me. Thank

you for believing in me far more than I believe in myself. There will never be another

Mary Ann Drake, you are a gift to this world and your students are forever impacted by

your endless advocacy, grace, and compassion.

I also dedicate this dissertation to my husband, Terry, and my children Sammy, Terry Jr.,

and Max. Thank you for giving me a reason to wake up each morning and do the work

that I do. Thank you for being patient and supportive as I have furthered my education for

all of these years. I love you so very much.

Lastly, I dedicate this dissertation to my mom and dad who taught me to work hard and

never give up. I was raised to believe that I could do anything I set my mind to, and I

have.

I wish to extend my deepest gratitude to Dr. Tokac for his advocacy, support, laughter,

and endless patience. You arrived in my life at the perfect time and are a true blessing. I

look forward to working on future projects with you.

I would like to thank Dr. Vandermause and Dr. Bender for being gracious and lending

their expertise to my dissertation. Your kindness and mentorship will never be forgotton.


Abstract

The world is struggling with the severe acute respiratory syndrome coronavirus 2

(SARS-CoV-2) pandemic and the need for disaster nursing education has never been

more clear. Recently, the American Nurses Association reported that of the over 32,000

nurses surveyed; only 11% felt well prepared to care for a COVID-19 patient (ANA,

2020). Community health nurse educators are tasked with educating future nurses on

disasters, yet, little is known about this population’s perceived competence in disaster

preparedness. The purpose of this study is to describe community health nurse educators'

perceived competence in disaster preparedness.

The study is a descriptive, correlational design used to measure community health

nurse educator's perceived preparedness for disaster response. The study examined the

relationships between community health nurse educator's perceived preparedness and

personal attributes and self-regulation (motivation).

Two findings were statistically significant. First, if community health nurse

educators had actively participated in a disaster event in the past, they reported greater

perceived competence in disaster nursing preparedness (p=.001). Second, the higher the

level of self-regulation the more familiar community health nurse educators were with

disaster preparedness.

Community health nurse educators are on the frontlines of healthcare’s response

to a disaster. Community health nurse educators must stress the importance of the nurse’s

role in disaster preparedness to administrators and professional organizations of nursing,

and provide themselves, and students, with the self-determination to take the risks

involved in preparing and acting in a disaster.


Chapter One: Introduction

Community Health Nurse Educators and Disaster Nursing Education

Disasters can destroy lives within a matter of moments, often without warning.

The incidence of disasters is on the rise in the United States, with the Federal Emergency

Management Agency (FEMA) reporting an average of 43 disasters declared annually

(Zotti, Williams, Robertson, Horney, & Hsia, 2013). The United States has experienced

a series of these tragedies over the last several years, which have resulted in a significant

loss of life and the security that so many citizens have become accustomed to. No

Americans are immune to the potential of destruction and trauma that disasters leave

behind. With the world in the middle of the severe acute respiratory syndrome

coronavirus 2 (SARS-CoV-2) pandemic, as this study is conducted, the need for disaster

nursing education has never been more clear. Recently, the American Nurses

Association found that 87% of nurses feared going to work, 36% have cared for a

COVID-19 positive patient without having adequate personal protective equipment

(PPE), and of the over 32,000 nurses surveyed; only 11% felt well prepared to care for a

COVID-19 patient (ANA, 2020). This further exposes the gap in what nurses need to

know in a disaster compared to how well they know it. The purpose of this research study

is to describe community health nurse educators' perceived disaster preparedness and

competence in educating the future nurses of America.

Background of Problem

Due to the vast array of causes and effects of disasters, it is difficult for nurses to

gain a comprehensive and cohesive understanding of disaster preparedness and

management. When examining disasters as a whole, the end result and needs are similar


for any mass casualty event. Regardless of type or cause, the health care workforce,

living in any part of the nation, is vulnerable to a disaster event. With this knowledge,

attention should be given to the perceived preparedness and competence of community

health nurse educators in the United States. This population is the group of professionals

who are responsible for incorporating disaster nursing curriculum into their already

content-packed community health nurse courses.

It is difficult to find one agreed-upon definition of disaster in the literature

considering the differing types and impacts of these events. Oztekin et al., (2015)

explained that a disaster is “a serious disruption of the functioning community or a

society causing widespread human, material, economic, or environmental losses which

exceed the ability of the affected community or society to cope using its own resources”

(p. 99). This definition covers the breadth and depth of disasters which can be natural or

manmade. The American Red Cross (2003) goes into greater detail in their definition; “A

threatening or occurring event of such destructive magnitude and force as to dislocate

people, separate family members, damage or destroy homes, and injure or kill people. A

disaster produces a range and level of immediate 0suffering and basic human needs that

cannot be promptly or adequately addressed by the affected people, and impedes them

from initiating and proceeding with their recovery efforts. Natural disasters include

floods, tornadoes, hurricanes, typhoons, winter storms, tsunamis, hail storms, wildfires,

windstorms, epidemics, and earthquakes. Human-caused disasters—whether intentional

or unintentional—include residential fires, building collapses, transportation accidents,

hazardous materials releases, explosions, and domestic acts of terrorism”


Natural disasters may include events such as an earthquake, tornado, hurricane,

tsunami, volcano, or flooding. Man-made disasters may include events such as

biochemical terrorism, chemical spills, nuclear events, fires, explosions, transportation

accidents, gun violence, and warfare (Veneema, 2017). Communicable disease outbreaks

and pandemics are another type of disaster that warrant research and understanding. The

H1N1 Influenza pandemic was a reminder of the ability of viruses to wreak havoc on the

healthcare system, and that poor public health preparedness anywhere in the world can

impact the United States (Moore, 2012). We are reminded of this again with the current

COVID-19 pandemic and the impact it has had on our country and the world. While

disaster type, cause, and definition may vary significantly, the outcomes can be equally

horrific.

A renewed sense of commitment to disaster preparedness and management began

after the terrorist attacks on the United States on September 11, 2001. This disaster

shook America to its core and exposed the fragility of the country and its citizens. The

events of that day solidified disaster preparedness as a national security priority (Moore,

2012). The majority of the new training that resulted from this event, focused mainly on

military and government settings (Wisniewksi, Dennik-Champion, Peltier, 2004). “Major

changes were made by the Bush administration to avoid and respond to potential mass-

casualty disasters, most notably through the development of Homeland Security”

(Wishniewski et al., 2004). Hurricane Katrina in 2005, once again, brought attention

back to the need for extensive disaster preparedness. This event was an awakening, not

only to the government but also to the healthcare community. Nurses recogognized the

need for futher disaster training, beyond basic nursing skills (Stangeland, 2010). Nurses,


physicians, and other healthcare professionals worked without electricity and quickly ran

out of medications and supplies trying to care for patients.

Mass casualty shootings have also impacted the importance of disaster

preparedness and management, especially in the healthcare and first responder settings.

A school shooting in Newtown, CT. occurred on December 14, 2012, leaving 28 dead

and two injured (Schumacher-Matos, 2012). The Orlando Pulse night club shooting in

Florida on June 12, 2016, occurred two blocks from the Orlando Regional Medical

Center. Due to the close proximity, numerous victims were brought to the center rapidly

and without warning. The facility received 49 victims, a SWAT team member, nine

succumbed to their injuries, 17 presented to other hospitals, and a total of 40 victims died

in the club (Bloch, Hersher, Domonoske, Kennedy, & Dwyer, 2016). This facility

participated in a tri-county active shooter mass casualty intake drill, which proved to be

beneficial. Emergency department (ED) physicians and nurses were forced to triage and

care for patients being dropped off in trucks. This demonstrates one example of a

situation that nurses may find themselves in.

Other mass casualty shootings that have occurred in recent years include loss of

more lives. The Las Vegas shooting on October 1, 2017, resulting in 58 deaths and more

than 850 wounded (Wamsley, 2017). A school shooting occurred in Parkland, Florida, at

Marjory Stoneman Douglas Highschool, leaving 17 dead and 17 injured (Wamsley &

Gonzales, 2018). Sadly, these examples only touch the surface of the disasters that have

affected the United States in recent history.

With the overall incidences of disasters on the rise and the everchanging global

effects of climate change, it is time to assess and address the disaster preparedness


education of nurses. Nurses are the largest group of healthcare professionals and are

consistently voted as the most trusted profession. In Gallup’s 2019 poll assessing ethics

and honesty, the most trusted profession was nursing for the 20th year in a row (Gallup,

2019). Nurses know their communities, are comfortable with treating the most

vulnerable patients, have knowledge of resources, and have assessment and clinical skills

that are determinantal in a disaster (International Council of Nurses, (ICN) 2009). Due to

this, nurses are able to reach the most vulnerable in their communities, offer resources,

work collaboratively with outside organizations, and care for the injured. It is logical that

nurses would either be on the frontlines of a disaster or, at the very least, sufficiently

trained to act in a capacity that would allow them to protect and care for themselves and

their patients.

As previously mentioned, disasters vary, but this should not prevent nurses from

being prepared. The outcomes of the examples mentioned previously are mass casualties

that require all nurses to feel confident in their ability to assist in some way. An all-

hazards approach, which is recommended by the Federal Emergency Management

Agency (FEMA), would allow nurses and other responders to be prepared for any mass

casualty event (Veenema, 2017). This means that training would provide a foundation of

preparedness that could be effective in any disaster. All hazards preparedness takes the

personalization out of training so that the focus is not on the type of disaster but on the

main aspects that pertain to mass casualties.

All nurses may not agree that they need to be trained in disaster preparedness and

management. Many may believe that this role is for public health nurses only, however,

when a disaster strikes, and mass patients are delivered to the ED, nurses of all specialties


are needed. Nurses have a history of volunteering to assist in disasters, but often because

of their compassionate nature and not necessarily because they feel prepared (ANA,

2017). A small number of nurses have ever assisted in a disaster, and many of those who

have are not adequately prepared (ICN and WHO, 2009). In the event of a disaster,

nurses may choose to volunteer, may already be present at work, or may decide to come

into work on over-time (ANA, 2017). Regardless of how nurses find themselves face to

face with a disaster, it is vital that nurses, as frontline providers, are knowledgeable about

disaster response, because this will save patients’ lives. Wisniewshil, Dennik-Champion,

and Peltier (2004) note that healthcare advocates are unanimous that nurses need to be

educated to respond to disasters. Robinson (2010) explains that "experience in many

disasters suggests that although teams of experts may later fly in to help, it is the

available services from local hospitals and clinics that are called upon to provide

immediate assistance" (p. 1). The healthcare personnel who help in these instances are

often left to work with confusion and lack of guidance (Nasrabadi, 2007).

There have been limited studies that focus on the disaster preparedness of nurses

in the literature (Labrague et al., 2018). Those that have been conducted involve the

generalist nurse, emergency nurses, military nurses, or public health nurses. Often, these

studies show that nurses do not feel prepared or competent to manage disasters including

students and faculty in nursing programs (Charney, 2019). A few studies have been done

on the preparedness of hospital nurses. Nurses report feeling unprepared and lacking the

skills to be efficient caregivers and leaders in the disaster setting. The Crisis Standards of

Care (IOM, 2009) noted that hospitals, walk-in clinics, and private practices need crisis

response plans that designate the shift from conventional standards of care to providing


essential services during a disaster. That is a heavy charge for medical facilities, and

nurses are expected to be able to make that shift along with their leaders and peers, often,

at a moment's notice. A robust nursing workforce is needed for a hospital to handle a

disaster appropriately and effectively (McHugh, 2010).

The population who will be educating nurses, soon to be entering the workforce,

are community health nurse educators. If this group can explain their level of

preparedness and perceived competence, it makes sense to start there, and work forward,

to eventually create a disaster curriculum that would benefit all nurses and communities.

Understanding the perceived competence of community health nurse educators, will

reveal the disaster content areas in which educators are familiar or unfamiliar with

various aspects of disaster preparedness. Baack and Albers (2013) describe the need for

an understanding of the perceived preparedness of nurses in the United States that

differentiate the mediating factors. The authors were able to show that nurses reported

feeling unprepared for a disaster and the need for further research and training (Baack &

Albers). Examining community health educators may lead to a greater understanding of

why they may or may not incorporate disaster preparedness content into the courses they

deliver to students. According to Stangeland (2010) “nursing school governing bodies

have developed competencies to be included in the nursing curriculum; however, nursing

programs have been identified as still lacking in the area of disaster nursing curriculum

(p. 425).”

A few studies have been done on the preparedness of hospital nurses. Nurses report

feeling unprepared and lacking the skills to be efficient caregivers and leaders in the

disaster setting.


The Study

The study is a descriptive correlational design. Community Health Nurse

Educators were surveyed using Qualtrics on their perceptions of competence in disaster

preparedness. The instrument will be described in detail in the methods section but

included 55 questions that are simple multiple-choice, a couple of yes/no, and Likert-type

questions. The research questions to be answered in the research are as follows;

1. What is the perceived competence of community health nurse educators regarding

their disaster preparedness?

2. Which of the variables - individual differences; geographic location, role (nursing

background), age, years of nursing, years of teaching, importance of disaster

education and previous disaster experience, and self-regulation most influence

perceived competence in disaster preparedness?

3. Is there a relationship between self-regulation scores and perceived competence in

disaster preparedness?

4. Is there a relationship between perceived competence in disaster preparedness and

the perceived importance of disaster education?


actively participating in a major disaster event?

Significance of the Problem

The majority of disaster nursing literature is focused on hospital nurse’s post-

disaster, which is reasonable considering that is where patients will end up for care after a

disaster. There are limited studies, however, that examine the perceived preparedness of

nursing students and nursing educators. It is easy to make the connection that if


community health nurse educators feel unprepared, community health nursing students

and working nurses most likely do too. The burden falls on community health educators

to take a leadership role; however, the gap in the literature in regard to their knowledge

makes it difficult to know where to begin this endeavor.

Value to Nurses

Research has shown that nurses feel inadequately prepared to act in disasters and

that disaster content in curriculum is lacking in academic programs. Weiner, Irwin,

Trangenstein, & Gordon (2005) conducted a study that examined the level of disaster

preparedness curricula in the United States nursing schools. The study consisted of 348

nursing programs who answered the survey, with 5 filling it out incompletely, and 45 of

the 50 states represented and Puerto Rico (Weiner et al.). The results showed that a

minimal amount of curriculum (if any) was devoted to disaster content and that "74% of

students felt that the faculty were not at all prepared or were poorly prepared" to teach the

disaster content (p.338). Only "5.2% of the sample" answered that the faculty was well

prepared to teach the content (p. 338). These results are a red flag and should represent a

concern for community health nursing educators. If the faculty educating the students

aren't adequately prepared, how can nursing students be expected to learn the material?

While there is a need for further research on preparedness and nursing, there is

also a wealth of information to begin making changes. Currently, disaster nursing

education is sporadically provided in a community health course, continuing education

modules, or through the workplace, when taught at all. This education is developed from

various recommendations or a combination of competencies including; AACN, ICN,

WHO. What is missing from the literature is the perceived disaster preparedness of the


community health educators who are charged with including this content in an already

packed curriculum. In traditional undergraduate nursing courses, faculty are teaching

students based on the preparation of the NCLEX (Veenema et al., 2017). There are

limited, if any, questions asked on the NCLEX about disaster preparedness, which

minimizes the importance of fitting disaster content into community health courses. It is

known that many of the basic skills required for disaster preparedness are taught across

the undergraduate nursing curriculum; however, nurses still feel unprepared for many

aspects of disasters. There has been minimal literature that focused on educators.

Since the disaster nursing content falls in community, public, and population

health textbooks and is recommended by the AACN essentials, it makes sense to assess

community health nurse educators as a beginning to coordinating a standard of required

disaster education in nursing programs. If community health nurse educators do not feel

prepared, this will give us a glimpse into where, to begin with, disaster education. This

information could potentially lead to education for educators. Community health nurse

educators could obtain training or education and then build upon that knowledge to carry

out the information to their students. An all hazards approach could be used with more or

less of a focus on specific types of disasters depending on the area of risk. The Johns

Hopkins Bloomberg School of Public Health Recommendations for Improving National

Nurse Preparedness for Pandemic Response could be used as a guide, along with the

research and guidance of disaster nursing experts (2020).

The AACN BSN Essentials published in 2008 states that "the baccalaureate

program prepares the graduate to Use clinical judgment and decision-making skills in

appropriate, timely nursing care during disaster, mass casualty, and other emergency


situations" (p.25). This specific reference to disaster nursing preparedness falls under

Essential VII: Clinical Prevention and Population Health. The AACN published a

follow-up supplement to the essentials of baccalaureate competencies and curricular

guidelines specifically for public health nursing (AACN, 2013). This supplement

"motivates the use of strategic planning frameworks to design health promotion and

education programs" (p. 21). It also provides a teaching strategy for the topic of

interprofessional communication and collaboration for improving patient health

outcomes, which is aimed at disaster nursing; "introduce students to strategies for clear

team communication in challenging high-stress situations such as accidents, mass

casualty, or disease outbreaks" (p.20).

While disaster preparedness is a core component of nursing programs, many

nurses are still not equipped with the skills to manage disasters. Students report that their

education does not adequately address the foundation of disaster preparedness (Charney,

2019). This study will address the where the disconnect in education is occurring. the

community health educator's perspective of competence in managing disasters. This, in

turn, will add information to assist in curriculum needs and improved the care of victims

after a disaster.

Competencies

The ICN Framework of Disaster Nursing Competencies includes guidance for all

nurses. According to (ICN/WHO, 2009), "The sporadic nature of disaster nursing

education has resulted in a workforce with limited capability to respond in the event of a

disaster, develop policy, educate, or accept leadership roles" (p. 28). The document also

touches on the lack of confidence that faculty feel due to being unprepared to teach


disaster nursing. "The lack of formal education has created a workforce with little or no

competency in disaster nursing" (ICN/WHO, 2009, p. 30). It is recommended that

disaster is taught in the classroom and online using the standard competencies which fall

under the disaster management continuum; risk reduction, disease prevention, and health

promotion, policy development and planning; ethical practice, legal practice, and

accountability, communication and information sharing, education and preparedness; care

of the community, care of individuals and families, psychological care, care of vulnerable

populations, long-term individual, family, and community recovery. Nurses should play a

role in all areas of the disaster continuum.

Another document that provides support for disasters is the guidance for

establishing standards of care (IOM, 2009). This is for use in disaster situations, and a

piece of guidance includes directions for clinical care in disasters. These include surge

capacity strategies such as the implementation of community-based triage capabilities

and risk communication about when to seek care. These strategies, when used correctly,

can reduce the burden on healthcare demand. The Crisis Standards of Care call for all

healthcare facilities to have a plan in place in the event of a crisis. The standards of care

suggest a continuum of care that is set into place in a mass casualty event. This guidance

includes five key elements; strong ethical grounding, integrated and ongoing community

and provider engagement, assurances regarding legal authority and environment, clear

indicators, triggers, and lines of responsibility and evidence-based clinical processes and

operations (Altegogt, Stroud, Hanson, 2009). Nurses will serve a significant role if

following these standards.


The Quad Council Coalition (QCC) of Public Health Nursing Organizations (now

the Council of Public Health Nursing Organizations) is comprised of the Alliance of

Nurses for Healthy Environments (AHNE), the Association of Community Health

Nursing Educators (ACHNE), the Association of Public Health Nurses (APHN), and the

American Public Health Association-Public Health Nursing Section (APHA-PHN).

Further guidelines are provided by this set of standards. The QCC was founded in 1988

“to address priorities for public health nursing education, practice, leadership, and

research and as the voice of public health nursing” (QCC, 2018). Domain 7: Financial

Planning, Evaluation, and Management Skills include competencies across all three tiers

of public health nurses. These include the ability to explain the public health nurse’s role

in disaster response, develop partnerships that have authority over emergency

preparedness, and to demonstrate leadership across agency partnerships that have

authority over emergency preparedness (QCC, 2018). Community health nurse educators

are nurses with experience and training who are able to educate future nurses on these

topics.

As mentioned previously, the AACN Essentials historically have mentioned

disaster preparedness in the essentials. A new draft of domains has recently been

released that show population health as its own domain. Domain 3: Population Health

includes the descriptor; engagement in partnerships to support and improve equitable,

population health outcomes. It is difficult to know what this domain will include, but

with population health being its own domain, emergency preparedness will most likely be

included in this area. With more focus on population health, social determinants of


health, vulnerable populations, and emergency preparedness may get more attention and

visibility.


Chapter 2: Literature Review

Disaster Nursing Education

As previously mentioned, natural and man-made disasters frequently happen in

the United States and around the world. The results of these disasters are oftentimes

devastating and debilitating to those left in their wake. Regardless of type or cause, the

health care workforce, living in any part of the nation is vulnerable to a disaster event.

Those who live on the coast are no longer the only ones who should be prepared. With

this knowledge, attention should be given to the preparedness and perceived competence

of community health nurse educators in the United States.

Nurses have learned valuable lessons from disasters in the past. Hurricane Katrina

in 2005 and Hurricane Sandy in 2012 are just two of many examples. While mass

casualty care is a significant part of disaster nursing that nurses should be prepared for,

forced evacuations is another. Long term care facilities and hospitals, while rare, have

been forced to evacuate in disasters historically. This adds another level of preparation

for the nursing profession. Vandeventer, et al., (2017) adds the issue of loss of power

along with forced evacuation as another blow to the healthcare profession in a disaster.

Nurses who have experienced this in the past can assist in ideas to improve and create

disaster nursing curriculum as a basis for nurses who may very well assist in a disaster as

a registered nurse.

Disasters leave behind many victims. Nurses who work in and after a disaster are

victims alongside their patients. Many nurses don’t know the status of their own families

and are taking on the care of their patients and facilities. The ethical and legal challenges

that go along with disaster nursing is another aspect of disasters to consider. According to


Aliakbari, et al., (2015), there are two subthemes that fall under the theme of ethical and

legal challenges. Those themes are; "professional ethics explores professional

responsibility of nurses, as well as a sense of ethical obligation and adherence to the law,

refers to nurse's familiarity with and observation of legal requirements" (Alkiakbari et al.,

2015, p. 493). Nurses who respond in a disaster face great challenges and deserve to feel

as prepared as possible to handle the situation. Disaster nursing education can aid in

preparing nurses for these ethical and legal dilemmas that might keep them from working

in a disaster scenario.

Disasters occur every day throughout the world, according to the Pan American

Health Organization (2000). While the impact of disasters vary in severity, they all

threaten the quality of life to some extent. World Disasters Report 2007 showed a 60%

increase in disasters in the years 1997-2006 compared to 1987-1996. With the increase in

disasters, an increase in deaths, and in people affected by disasters also increased

(Klyman, Kouppari, & Mukheir, 2007).

The need for qualified public health workers to participate in disaster preparedness and

management exercises and training is well documented (ICN & WHO, 2009). According

to the IOM Report Brief (2009), "in order to ensure that patients receive the best possible

care in a catastrophic event, the nation needs a robust system to guide the public,

healthcare professionals and institutions and governmental entities at all levels." The

report brief also emphasizes the need for consistency in crisis care protocols, standards,

and key elements. The vision of the ICN (2009) includes fairness, equitable processes,

community and provider engagement, education, communication, and the rule of law.

Nurses at all levels are poised to be a significant part of the disaster preparedness and


management team. According to Yin, He, Arbon, & Zhu (2011), “nurses are renowned

for their flexibility and resourcefulness. Therefore, in an emergency or disaster situation,

it is common for nurses to undertake roles that are outside their normal scope of practice,

potentially leading to situations where they are asked to undertake duties that are beyond

their knowledge or abilities” (p. 269).

Barriers for Nurses

Nurses face multiple barriers in obtaining the proper disaster preparedness

training once they are out of school. If disaster preparedness is not learned in nursing

school, this impacts all areas of the nursing profession. Some examples of nursing

impacted are hospital nurses, school nurses, and community health nurses. Hospital

nurses and nursing students have been mentioned, but it is the entirety of the nursing

profession that needs a foundation for disaster education and this begins in nursing

programs. Another group of nurses who are pivotal after a disaster and would benefit

from improved disaster nursing preparedness and management are school nurses. After a

community suffers from a disaster, school nurses assist children and families who are left

behind. "47,000 nurses in the United States provide the resources that begin to bridge the

gap between schools, students, families, and the healthcare community" (Evers &

Puzniak, 2005, p. 232). With this connection between the nurse and community, it is

evident why disaster education would be especially important for this group of nurses.

Evers and Puzniak (2005) conducted a study showing the need for training among school

nurses. The survey results showed that more training and preparation were needed and

that respondents, specifically in Missouri, showed perceptions of the incidence of a


disaster were unlikely (Evers & Puzniak, 2005). This could explain why some nurses are

not motivated to attend disaster training or focus on disaster education importance.

The ICN and WHO disaster nursing competencies call for a basic foundation of

disaster nursing for all nurses. This is imperative considering the needs for qualified

workers in the healthcare workforces and the number of casualties with each event.

Another group of nurses who are considered to be first responders in public health nurses.

Just as nurses are the largest group in the healthcare profession, public health nurses are

the largest group in the public health profession (Chiu et al., 2011). Due to this, public

health nurses also need adequate training. Some of this training will be done once a nurse

enters the public health workforce, likely through FEMA. If these nurses receive disaster

education in their nursing programs as well, they will be better prepared for the advanced

training that they should receive as public health nurses.

The issue of nurses feeling unprepared or having inadequate disaster training is

not specific to the United States. This appears to be a global issue, as well. There have

been instances where nurses have acted in a disaster without any training at all. Yan,

Turale, Stone, & Petrini (2015) found that nurses who responded to earthquakes in China,

none had ever received disaster training prior. These nurses learned by trial and error in

an actual disaster and the days and weeks that followed. Lessons are learned in a disaster,

and changes are made after the event, but time and money can be saved by properly

training nurses in school.

There are expectations and criteria that must be addressed at each level, laying the

groundwork for disaster nursing. This should speak to curriculum development, but the

content is still often touched on infrequently. A disaster nursing expert panel purposed


the need to establish national guidelines for disaster response for schools of nursing

(Veenema et al., 2017). These guidelines would potentially guide schools in their roles in

the event of a community disaster.

The National Council Licensure Examination (NCLEX) also plays a role in

disaster nursing education in the curriculum (Veenema, et al., 2017). The disaster nursing

expert panel mention that since many undergraduate nursing programs teach according to

the NCLEX, it is less likely to be focused on as an area of study (Veenema et al., 2017).

Since very few test questions focus on disaster, course content is spent on other more

frequently tested areas. With limited classroom time and many concepts to teach in order

for students to be successful on the exam, disaster education is often one of the subjects

given less attention. The disaster nursing expert panel came up with two

recommendations for this issue; “add more questions specific to disaster and emergency

preparedness or add a state-based addendum to the examination that covers this content”

(Veenema et al., 2017, p. 691). The panel and their recommendations are a reminder and

encouragement as to why this content is crucial for nursing students to learn. Colleges

and universities are being asked to include disaster in the nursing curriculum by the

AACN essentials and other experts on disaster and curriculum, yet some nurses and

faculty don't have the motivation to do so. As seen in the literature review, there are

numerous reasons for nurses to learn, teach, and feel confident and empowered by the

knowledge of disaster nursing.

Conceptual Framework

The Self Determination Theory (SDT) will guide this research study. 0This

theory is an organismic theory of motivation based on intrinsic needs. In 2000, Ryan and


Deci wrote that “the fullest representations of humanity show people to be curious, vital

and self-motivated” (p. 68). The importance of a topic and a person’s motivation

determines whether or not a person has the desire to learn or change behavior regarding

the topic. The origins of SDT are from three other theories; cognitive evaluation theory,

organismic integration theory, and causality orientations theory (Deci, 1985). The theory

explains behavior in the context of needs.

The (SDT) is fitting for many research areas but especially fitting for disaster

nursing education research since it is empowering and influenced by perceived

competence, which is what will be examined. Deci explained the theory in a TED Talk,

explaining that "instead of asking how to motivate people, you should instead ask; how

can you create the conditions in which other people will motivate themselves?" (Deci,

2012). Using the self-determination theory as a framework in which to understand

educators perceived perception of disaster preparedness can help to further gauge the

state of the science from a community health educators' perspective. This may result in

the need for further education, training, and resources for community health educators,

prior to their education of future nurses on this topic. Once a solid foundation of

knowledge is formed for the educators teaching disaster nursing content, conditions can

be created in which they can empower students to motivate themselves to engage in

disaster nursing and fully understand its importance.

It is possible that there is a reluctance to alter curriculum and add disaster content,

especially when nurses feel that that may or may not ever happen; to educators, nurses, or

nursing students. This thinking may lead to the false belief that people are safe from

disaster, and, as explained earlier in the paper, no one is ever completely safe. Perhaps a


helpful way to think of disaster preparedness is like health insurance while getting sick

isn't certain, the likelihood of getting sick at some point is high. So, getting health

insurance coverage is logical. The reluctance to include disaster content in community

health curriculum may also be a strategic calculation so that educators can focus on

content that nurses will use more often. The hesitancy to come together and create a

curriculum based on national competencies may be an issue of lack of intrinsic

motivation and value. This research will explore that with the foundation of the Self

Determination Theory.

The theory describes two types of motivation; controlled and autonomous. In

controlled motivation, the learner is seduced, ordered, or pressured into making a change

(Deci, 2012). This does not often lead to lasting and meaningful change. In autonomous

motivation, the learner or client has volition and choice, endorsement, find the task

enjoyable, and deeply valued (Deci, 2012). When something is deeply valued, individuals

are more likely to participate in the activity or behavior. Every nurse won't find disaster

nursing education to be something they deeply value; however, it would be extremely

beneficial to academia and nursing if community health educators did. If they see the

value in the content and the relevance to themselves, their students, and communities,

they are more likely to learn more themselves and teach it in an autonomously motivated

way. This way of teaching makes learning more engaging and fun, and students will be

more likely to absorb and value the information as well (Deci, 2012). It also explains the

appropriate fit of SDT and its constructs.

The three major factors to be used in the study are; individual differences, self-

regulation (including motivation and readiness), and perceived competence (Deci &


Ryan, 2002). These concepts will be used to indicate the concepts that may influence

community health nurse educators to be prepared for disasters. These are the three of the

four concepts that Baack and Alfred (2013) modified to fit disaster nursing research.

“These four factors form the basis for a person’s readiness, ability, and commitment to

take action in a disaster event” (Baack & Alfred, p. 282). The job climate (the fourth

factor of the theory) will not be used in this study as it is not appropriate to the research

questions. The stage has been set for further research aimed at disaster nursing and the

use of the Social Determination Framework.

Concept Definitions

Individual differences are related to the variety of responses and experiences of

community health nurse educators. These are the perceived forces that move a person to

act or to change a behavior (Deci & Ryan, 2002). In this research, individual differences

will explore what experiences will lead community health nurse educators to act in a

disaster situation. There may be some factors that influence this, such as exposure to a

previous disaster (Baack & Alfred, 2013) or an educator's view on the importance of

disaster nursing education. This will be done by examining demographic information in

the study and will be measured by the use of questions regarding; role, years in nursing,

years in academia (added for this specific population), age, ethnicity, and geographic

location (state). Two new researcher generated questions will be added specifically for

the community health nurse educator population, which ask; do you teach disaster

nursing in your community health course, and do you feel that disaster nursing education

is important for all nurses? These will both be yes or no questions. The individual

difference will show how past and current experiences have shaped the educator's


motivation to learn. "At their best, people are agentic and inspired, striving to learn,

extend themselves, master new skills, and apply their talents responsibly" (Ryan & Deci,

2000, p. 68). This quote is especially fitting for the nursing profession as lifelong

learners striving for evidence to take the best care possible of their patients.

Self-regulation of behavior, including motivation and relatedness, refers to the

internal motivation that influences whether or not a person chooses to act (Ryan & Deci,

2000). This aspect of the study will be measured by the three-question Self-regulation

survey as used in Baack & Alfred's (2013) research. The survey will show the likelihood

of community health educators acting in a disaster. The total score of the survey ranges

from 3-21 and is a Likert-type scale, with one being extremely likely and 7 being

extremely unlikely. This will add an interesting aspect that will reveal the motivation of

the community health nurse educator.

Perceived competence is described by Ryan and Deci (2000) as the level of

competence that one feels that determines their belief in reaching their intended goal.

This will be measured by the Emergency Preparedness Information Questionnaire

(EPIQ). EPIQ assesses familiarity of the eight competencies dimensions of emergency

preparedness (Garbutt et al., 2008). Alterations were made to the original 68 item EPIQ

tool to make it a more appropriate fit for community health nurse educators and will be

discussed further in the methodology section.

The concepts work together to result in a specific behavior. By looking at the

perception and competence of community health educators through the lens of the SDT,

new findings could emerge. Individual differences and self-regulation both directly affect

perceived competence. By examining the results of the surveys distributed electronically


to all Association of Community Health Nurse Educators, the goal is to find out what

factors may influence them to be prepared for disasters and to explore their perceived

competence in acting in and educating about disasters.

Framework Description

SDT is meaningful and can be used in a variety of ways in nursing, including its

application as a framework to view disaster nursing education. This study will use the

SDT and three of its concepts to address a gap in the literature. There is plenty of

research in the field of disaster preparedness and management; however, very little

focuses on the perceived preparedness and competence of nurses. None could be found

specifically targeting the disaster preparedness of community health nurse educators.

The research that does exist has added a foundation for future disaster research to be

implemented in a variety of ways.

The Association of Community Health Nurse Educators has roughly 275

members. The members are active and passionate about community health education

curriculum and improvement. The association has members from across the United States

and can offer a significant contribution to disaster nursing education. If community health

nursing faculty do not have the knowledge and confidence needed to educate students on

disaster education, that might be a solid starting point in which to begin to revise the

community health curriculum.

Each of the concepts in the SDT is related. Individual differences, healthcare climate,

and self-regulation all have a direct effect on perceived competence. This study will not

focus on healthcare climate but will use individual difference and self-regulation as the

guiding concepts of the framework. The community health nurse educator's perceived


competence in disaster nursing education may be influenced by these two concepts of the

theory and may, in turn, impact whether or not the content is taught. The concepts could

also influence whether or not an educator will advocate for curricular change if disaster

education is not being adequately addressed.

A long-term goal would be for the community health nurse educator to teach

disaster nursing content in nursing programs, using autonomous motivation, have

adequate course content devoted to it, and result in nurses who are a positive addition to

the disaster workforce. Another long-term goal would be for community health nurse

educators to autonomously seek out their own disaster preparedness and management

exercises and training and stay current with the topic. In this way, educators can keep up

with the latest approaches to disaster preparedness and use the information to share with

and educate their students. This would benefit nursing as a profession but, most

importantly, the residents of any community who experience any disaster.

SDT Exemplar

SDT has been used as a lens in which to examine many phenomena. It has been

combined with motivational interviewing in a study done by Vansteenkiste & Sheldon

(2006) to examine factors related to motivating therapeutic change. SDT has also been

used in numerous studies to investigate the intrinsic motivation that goes into behavioral

change, such as physical activity initiation. The work that SDT has informed that is the

most similar to this research study was done by Baack and Alfred (2013). The

researchers used SDT to examine the perceived competence of rural nurses regarding

their disaster preparedness.


The theory could also be relevantly applied to examine community health

educators and their perceived competence of disaster preparedness with a similar

approach. After altering a few focused demographic and research questions, the

application can be easily revised to survey a different population. Baack and Alfred's

(2013) research examined the state of disaster preparedness of nurses in Texas. The

research study focused on a specific demographic; two healthcare systems and two small

rural hospitals in Texas and included nurses with varying degrees of disaster experiences.

The research conducted by Baack and Alfred (2013) influenced this study and

examined rural nurses' preparedness and perceived competence in managing disasters.

Certain aspects of the SDT was used to underpin their study. The goal of the study was

to "describe the current status of the nurse's preparedness to manage disasters in order to

help communities, and healthcare systems strengthen their emergency response

programs" (Baack & Alfred, p. 281). This goal is similar to the goal of community health

nurse educators and can be modified to fit the educators to help communities, healthcare

systems, nursing, and academia.

The study was able to show that disaster experience, individual differences, and

self-regulation were significant predictors of the nurse's perceived competence in disaster

preparedness (Baack & Alfred, 2013). These findings were explained by using each of

the

SDT factors. The findings of the study were consistent with previous nursing research

(Fung et al., 2009; Garbutt et al., 2008; Gebbie & Qureshi, 2002) by showing that most

nurses reported a perception of low to average competence in disaster preparedness

(Baack & Alfred).


Some of the methods used in Baack and Alfred’s study can be used to assess the

state of disaster preparedness of community health nurse educators from across the

United States. The theory chosen is a relevant framework in which to view disaster

nursing preparedness and explain the findings. The study will reveal new data to add to

disaster research with a unique and important sample population. It will provide a broad

sample from varying geographic locations who share specialized roles as community

health nurse educators.

Baack and Alfred (2013) noted that a limitation of their study was that it was

focused on nurses, specifically in rural areas of the state of Texas. The study

recommended replication in other geographic regions. While this research is crucial to

the disaster nursing curricular planning and the safety of disaster victims, it can also be

used in other ways. The body of literature on disaster nursing education does not include

research specifically on community health nurse educators. If a university or college

offers a community health nursing course, it is likely where disaster nursing education

would fall. Community health nursing textbooks dedicate chapter(s) to disaster content.

That is why research to focus on this specific population would benefit the direction of

disaster preparedness and management. The research would span the United States and

fit the recommendation of Baack and Alfred's (2013) request to perform research in

further geographic regions.

Theory Comparison

The complexity of disasters adds to the difficulty in narrowing in on a theory in

which to examine disaster research. The choice of a theory also depends on the aspect of

the disaster being examined. Disaster literature often focuses on the immediate skills and


tasks needed in each phase of disasters using the continuum as the framework

(Sementelli, 2007). As with any topic, conflicting perspectives can also cause barriers to

the development of a theory related to disasters (Muhammad, 2018). After reviewing the

literature and health behavior theories appropriate to examine disaster, two theories stood

out; the Self-determination theory (SDT) and the theory of planned behavior (TPB).

Self-determination theory (SDT) (Deci & Ryan, 1985, 2012) and the Theory of

Planned

Behavior (TPB) (Ajzen, 1991) are two popular health behavior theories. Both were

examined when preparing for this study. SDT argues that individuals are motivated when

certain intrinsic needs are met. These basic needs include autonomy, competence, and

relatedness, and if met, can impact behavior in a specific context (Hagger, Chatzisarantis,

Culverhouse, & Biddle, 2003). Another theory that was examined was the Theory of

Planned Behavior (TPB). This theory purposes that behavior change is determined by

attitudes, subjective norms, and perceived control. The focus of TPB is that intentions

largely predict behavioral engagement (Conner & Norman, 2005). Previous research has

shown potential causal pathways between SDT and TPB; however, the overlap between

concepts of the theories are not clear (Hagger et al., 2003). The theory of planned

behavior purposes that the key predictor of behavior change is intent while SDT purposes

that the key predictor of behavior change is motivation.

The concepts of TPB are attitudes, subjective norms, and perceived behavioral

control (Ajzen, 1991). These concepts are thought to influence the intentions of an

individual and are deeply extrinsic. Attitude is an individual’s evaluation of the benefits

of engaging in a particular behavior. Subjective norms are the opinions of others related


to the behavior. Perceived behavioral control is an individual’s perception of being able

to accomplish the behavior (Ajzen). According to Ajzen, the concepts are obtained

throughout life experience over time and impact an individual to engage in a behavior.

When examining behavior change through the lens of TPB, there are external pressures

and forces that influence change, this type of change is not thought to persist long term

(Ryan & Deci, 2000).

Examining the SDT and TPB together, SDT appears to be a better fit in which to

explore the perceived competence of community health nurse educators. Educating

nurses or nursing students has some extrinsic pressures and factors, but what drives

nurses is intrinsic. Their patients are important to them, so they take care of them. They

want their care to be the best, so they seek out extra training. More often these days,

nurses work autonomously. Their intuition and critical thinking save lives. This is what

motivates them, not extrinsic pressure. When discussing the importance and the need for

disaster preparedness and education, motivation has the potential to promote lasting

change. While the intention is extremely important in behavior, it is the motivation that

will encourage and empower nurses to act.

Fostering motivation to learn, teach, and participate in disaster nursing education

is an important move in the right direction. Deci and Ryan explain that motivation

toward a specific behavior or activity will lead to approach-oriented beliefs toward

performing the behavior and intentions to engage in the behavior in the future. That is

what is needed for the future of disaster nursing education. This study will examine

perceptions of preparedness and intrinsic motivation to become prepared. Nurse are

naturally autonomous workers. They care for patients and interact with healthcare


providers from a place of autonomy and competence. This study will not look at external

influences and how they impact a community health nurse educator to become prepared,

although that could be interesting in further studies. The theory of planned behavior does

not include competence as a concept. It examines outside influences and impacts;

therefore, SDT is a better fit for the study.

The proposed study will use the SDT and the three concepts to address a gap in

the literature. There is plenty of research in the field of disaster preparedness and

management; however, very little focuses on the perceived preparedness and competence

of nurses. Baack initially tackled this topic in 2011. The research has added a foundation

for future disaster research to be implemented in a variety of ways. Baack and Aflred

(2013) noted that a limitation of their study was that it was focused on the state of Texas.

The study recommended replication in other geographic regions. While this research is

crucial to the disaster nursing curricular planning and the safety of disaster victims, it can

also be used in other ways. The body of literature on disaster nursing education does not

include a study on community health nurse educators. If a university or college offers a

community health nursing course, it is likely where disaster nursing education would fall.

That is why research to focus on this specific population would benefit the direction of

disaster preparedness and management.

The Association of Community Health Nurse Educators (ACHNE) is an engaged

entity of public health nursing. With its wide range of members across the United States,

it makes up a viable sample to survey. Members of ACHNE all teach public health,

community health, and population health courses to students in a variety of nursing

programs. The study will provide a view from a diverse group of educators teaching in


different levels of nursing. This could add depth and breadth to the disaster nursing

education literature that is already published. The findings may also contribute some

direction for future studies and substantial information on disaster content areas for

community health nurse educators to target.


Chapter 3: Methodology

The study is a descriptive, correlational design used to measure community health

nurse educator's perceived preparedness to disaster response. The study examined the

relationships between and among community health nurse educator's perceived

preparedness and personal attributes and self-regulation (motivation). The demographics

included; geographic location, role (nursing background), age, years in nursing, years of

teaching, the importance of disaster education, and previous disaster experience.

Sample/Sampling Frame

The sample population included community health nurse educators (n=123). The

educators who participated in this study are nationally representative. IRB approval was

obtained through the University of Missouri St. Louis IRB Committee. Permission was

sought, and granted, to use the Association of Community Health Nurse Educators as the

study sample. This was done via email and through the president of the organization. The

survey remained open for four weeks. Once the survey came down, the response rate was

n=68. With the goal of obtaining over 100 completed surveys, it was sent out again using

the snowball sampling technique. This time, ACHNE members were asked to share the

link with colleagues who are also community health nurse educators (though not

necessarily members of ACHNE). The final sample population resulted in a group of

community health nurse educators who teach in a variety of nursing programs and

universities.

This study examined the following research questions:

1. What is the perceived competence of community health nurse educators regarding

their disaster preparedness? Community health nurse educators perceived


competence in disaster preparedness will be measured using the EPIQ tool. This

tool will provide a range of scores suggesting the perceived competence of

participants.

2. Which of the variables - individual differences (geographic location, role (nursing

background), age, years of nursing, years of teaching, the importance of disaster

education and previous disaster experience), and self-regulation most influence


3. Is there a relationship between self-regulation scores and perceived competence in

disaster preparedness? The scores of the self-regulation measure and the EPIQ

tool in a multiple regression analysis.


the perceived importance of disaster education?


actively participating in a major disaster event?

Procedure

The inclusion criteria were that participants must be community health nurse

educators and/or members of the Association of Community Health Nurse Educators.

The recruitment plan included both active and passive strategies. An email was sent out

explaining the research study's purpose, risks, and benefits. Participant questions or

concerns were addressed via email, and participants were made aware that participation

in the research was voluntary. Data was collected electronically. A Qualtrics survey was

created and sent out electronically to the ACHNE listserve. The survey remained open

for four weeks, with a reminder email sent out at the two week and three-week marks.


This resulted in 68 completed surveys. A snowball sampling technique was then used. An

email was sent out again to the ACHNE Listserv requesting that members share the

survey link to community health nurse educators whom they may know, or work with.

This resulted in a population number of n=122 once all data was cleaned and incomplete

surveys removed. Participants were entered into a drawing to receive one of ten 25.00

Amazon gift cards as an incentive for their time. The survey was confidential and

identifying information in the form of email addresses were only included on those who

choose to be part of the gift care drawing.

Retention strategies that were used in the study included follow up, reduced

participation burden, and convenience. These strategies are recommended as important

aspects of any research (Mazurek, Melnyk, & Morrison-Beedy, 2019). Follow up will be

done by presenting or reporting the findings at a future annual meeting. Reduced

participant burden was done by reducing the number of items on the survey from 68

items to 55 items. Convenience was displayed by providing the survey online with a

direct link for participants to click to easily reach the survey.

Instrument

The EPIQ tool was created in 2003 and used in a large study conducted by

Wisnieweski, Dennik-Champion, and Peltier (2004). The tool consisted of 68 items

assessing nurse self-reported perceived familiarity and competence in emergency

preparedness. Throughout the study, the researchers expanded the tool to include self-

reported familiarity with emergency preparedness competency dimensions (Wisnieweski

et al.). This provides strength to the instrument and the data that it is able to extract.


The total summed score of the EPIQ is used as a measure of nurses’ perceived

competence in disaster preparedness. The authors found that the tool was valid and

reliable for assessing the perceived competence of nurses in emergency preparedness.

The validity and reliability particulars of the tool will be discussed later in this document.

Upon completion of the study, Wisnieweski et al. recommended that further studies be

done to examine nursing preparedness curricula.

The EPIQ tool consists of 10 dimensions of emergency preparedness. The

subscale dimensions include familiarity with the following; detection of and response to

an event (7 questions), incident Command System (ICS) (8 questions), ethical issues in

triage (4 questions), epidemiology and surveillance (4 questions), isolation and

quarantine (2 questions), decontamination (3 questions), communications and

connectivity (7 questions), psychological issues (4 questions), special populations (2

questions), and accessing critical resources (3 questions). These dimensions match up

nicely with the ICN framework (2009). The EPIQ tool has been used in numerous

research studies to date (including Baack & Alfred, 2013; Schneider, 2019).

Three questions of the Self-Regulation survey (Baack & Alfred, 2013) were

added to this study. These questions explored the community health nurse educator’s

likelihood (motivation), commitment to participate, and willingness to assume the risk of

participation in disaster preparedness. This combination of survey instruments provided

data from each of the constructs of the SDT. While the original EPIQ instrument

contains 68 questions, this number was decreased to 55 items to include only questions

relevelnt to this specific population. The survey also included self-regulation questions

and demographic questions specific to community health nurse educators. After


incorporating the Self-Regulation and demographic survey questions, the instrument used

in the study contained a total of 55 items.

Questions 1-7 were multiple-choice, yes or no, and fill in the blank and made up

the demographic portion of the instrument. Questions 8-52 addressed the familiarity with

emergency preparedness terms and activities and are Likert-style questions with one

being very familiar and five not being familiar. The total possible range of scores for this

section is 44-220. Questions 53-55 will be Likert-type questions with one being not likely

and five being very likely and address self-regulation.

Reliability and Validity of Instrument

The EPIQ tool was tested for validity and reliability by the creators of the tool.

The cumulative variance explained was 73.5%, and the coefficient alphas ranged from

0.83 to 0.94; these numbers show high levels of reliability (Wisniewski et al., 2004). In

2008, Garbutt, Peltier, and Fitzpatrick evaluated the EPIQ and reported Cronbach’s

alphas for the subscales ranged from 0.83 - 0.94 and 0.97 for the total instrument.

Garbutt, Peltier, and Fitzpatrick (2008) also evaluated the tool and found the Cronbach’s

alphas for the subscales ranging from 0.84 - 0.95 and 0.98 for the EPIQ total instrument

score. Baack and Alber’s (2013) found the EPIQ tool’s internal consistency reliability

was also strong in their study with Cronbach’s alphas for the subscales ranging from 0.84

– 0.95 and 0.98 for the EPIQ total score. In the most recent research in the literature

examining the perceived disaster competence of the study’s sample of emergency

department (ED) registered nurses, the alpha was .98 for the total EPIQ (Scheider, 2019).

The Self-Regulation (SR) survey was used in Baack and Alber’s (2003) and

contained three questions relating to self-regulation to engage in disaster preparedness


activities. The Cronbach’s alpha for the Self-Regulation survey in Baack and Alber’s

study sample was 0.91.

Instrument Exemplars

The two most relevant uses of EPIQ for the current study is by Baack and Albers

in 2013 and Schneider in 2019. Baack (2011) actually created her own tool, which was a

combination of the EPIQ survey, Nurse Assessment Readiness Survey (NAS), Self-

Regulation Survey, and Job Satisfaction Survey. The 58-item survey was emailed to over

500 nurses. Using these instruments, with the bulk of the questions coming from the

EPIQ scale, the researcher was able to provide valuable data for disaster nursing. This

study also used the SDT, which is the theory that will be used in the current study to

examine community health nurse educators.

While the study completed by Baack and Albers (2013) surveyed nurses in rural

Texas, the results of the study were consistent with the research in the literature. The

study reinforced the data that shows that nurses feel unprepared. Using the instruments

to obtain the data pertinent to the constructs of the theory, Baack and Albers were able to

show that intrinsic motivation does, in fact, predict disaster preparedness in nurses.

Baack and Albers (2013) recommended some major implications for practice and

future research. Ethical and psychological preparedness should be part of disaster

training. Public health organizations should hold disaster preparedness seminars and

exercises, along with acute care nurses. Public health nurses are in charge of setting up

shelters and the community at large, but that acute care nurses are needed to be ready to

act in a disaster. The main finding was that nurses do not feel prepared to assist in a

disaster. The major message that Baack and Albers reported was that training for nurses


must be consistent and ongoing throughout their careers. This sets the stage for the

current research to be conducted with community health nurse educators.

The second exemplar and the most recent to use the EPIQ in disaster nursing

research was conducted by Schneider (2019). This study used Patricia Benner’s Novice

to Expert Theory as a framework to guide his research but applied the EPIQ instrument in

the same way as previous studies, but this researcher also added a few extra instruments.

EPIQ (made up the bulk of the survey) but also included the Acknowledges Using

Intuition in Nursing Scale (AUINS), the Triage Decision Making Inventory (TDMI), and

a Demographic Data Information form designed by Schneider. This particular study

examined full and part-time emergency nurses with a BSN degree or higher.

The validity and reliability for this current study was conducted on the EPIQ scale

and the SR questions. The EPIQ scale (question numbers 9-52) had a Cronbachs Alpha

of 0.98. The EPIQ questions were highly correclated with perceived competence in

disaster nursing at a statistically signifcant level (p < .001) and total score range of 0.60

and 0.91. The SR questions had a Cronbachs Alpha of 0.89 (question numbers 53-55).

The SR questions were also highly correlated with the perceived competence in disaster

nursing at a statistically significant level (p<.001) and a total score range of 0.91-0.93.

The survey link was posted on a research website for nurses to participate

voluntarily. The study included nurses working in acute care settings in a determined

New York area. The participants were recruited through the Emergency Nurses

Association. This survey was done by using Qualtrics, which was also used in the current

study. Schneider found that the need for disaster nursing education is of utmost

importance. With Emergency nurses being on the frontlines, Schneider (2019) states, "it


is vital that hospital administration, government officials, and professional practice

organizations understand the importance of disaster preparedness knowledge and both

explore and promote innovative methods to educate and train nurses" (P. 91).

Data Analysis

Quantitative data analysis was conducted in this research study. One-way

ANOVA and independent t-test were used to analyze the data. A One-way ANOVA is

used to compare two or more groups of variables but is most beneficial for testing three

or more groups of variables. This test compares means to make inferences about data.

Assumptions of a One-way ANOVA include (Morgan et. al, 2011);

1. Observations are independent.

2. Variances on the dependent variable are across equal groups.

3. The dependent variable is normally distributed for each group.

A t-test is useful to use when comparing two groups of variables. T-tests can be

one tailed or two tailed which is the reason that this test is beneficial. According to

(Morgan, et. al, 2011) assumptions of an independent t-test include;

1. The variances of the dependent variable in the two populations are equal.

2. The dependent variable is normally distributed within each population.

3. The data are independent.

Independent and Dependent Variables

IV- The values used to predict the perceived competency of disaster preparedness

in community health nurse educators are; geographic location, role (nursing background),

age, years in nursing, years of teaching, the importance of disaster education, and

previous disaster experience.


DV- The value to be predicted is the perceived competence of disaster

preparedness in community health nurse educators.

Data was collected during the spring 2020 semester via a survey instrument. The

Qualtrics survey was sent out electronically to the sample population via the ACHNE

listserv with the link to the survey. The researcher did not collect individual emails or

names of the sample population except for those who choose to take part in the gift card

drawing. The data was collected and entered into SPSS Statistics version 26 for

Windows. Findings will be submitted for potential display at the Association of

Community Health Nurse Educators annual meeting in the summer of 2021.


Chapter 4: Results

This chapter explains the results of the data analysis including the quantitative

survey results. Demographics are described and key findings are highlighted. The survey

was open from February 20, 2020 to March 20, 2020. It was then reopened from April

30, 2020 to May 30, 2020, for a more robust response rate. Analysis of data was

conducted using the Statistical Package for the Social Sciences (SPSS 26.0).

Response Rate

122

Sample Size and Demographics

The demographic characteristics are depicted in Table 1 and represent both

frequency and percentages for geographic location, nursing background, age (generation),

years of nursing, years of teaching, perceived importance of disaster, and previous

disaster experience. More than half of the nurses surveyed have been nurses for 30 years

or more (52%) and fall into the baby boomer (born between 1946-1964) category (60%).

Of the total sample, 26.8% have been teaching community health nursing for 0-10 years

and 87% have a community/public health background.

Table 1

Demographic Variables of Survey Respondants

Geographic Location Frequency %

Alabama 2 1.6

Arizona 1 0.8

California 1 0.8


Colorado 3 2.5

Connecticut 1 0.8

Florida 3 2.5

Georgia 1 0.8

Idaho 1 0.8

Illinois 10 8.2

Indiana 3 2.5

Iowa 5 4.1

Kansas 1 0.8

Kentucky 2 1.6

Maryland 4 3.3

Massachusetts 3 2.5

Michigan 1 0.8

Minnesota 3 2.5

Mississippi 5 4.1

Missouri 4 3.3

Nebraska 1 0.8

New Jersey 3 2.5

New Mexico 2 1.6

New York 12 9.8

North Carolina 5 4.1

Ohio 5 4.1

Oregon 1 0.8


Pennsylvania 5 4.1

Rhode Island 1 0.8

South Carolina 2 1.6

Tennessee 2 1.6

Texas 17 13.9

Utah 2 1.6

Virginia 2 1.6

Washington 2 1.6

Wisconsin 5 4.1

Wyoming 1 0.8

Nursing Backgrounds Frequency %

Ambulatory 17 13.9

Community/Public Health 107 87.7

Critical Care 13 10.7

Emergency Services 15 12.3

Medical Surgical 21 17.2

Maternal Child 20 16.4

Operating Room/PACU 6 4.9

Pediatrics/Neonatal 10 8.2

Psych/Mental Health 9 7.4

Other 30 24.6

Years as a Nurse Frequency %

0-5 years 3 2.5


6-10 years 5 4.1

11-15 years 6 4.9

16-20 years 9 7.4

21-25 years 13 10.7

26-30 years 23 18.9

Greater than 30 63 51.6

Years as a Community Health Nurse Educator Frequency %

0-5 years 33 27.0

6-10 years 32 26.2

11-15 years 17 13.9

16-20 years 13 10.7

21-25 years 11 9.0

26-30 years 6 4.9

Greater than 30 10 8.2

Generation Frequency %

Millennials 9 7.4

Generation X 38 31.1

Baby Boomers 74 60.7

Silent 1 0.8


Descriptive Statistics of the Main Variables

The descriptive statistics for the main variables include the mean, standard

deviation, and actual ranges of the main variables of the study. The 44 disaster familiarity

questions (EPIQ) were measured on a Likert scale with 1=very familiar and 5= not

familiar. The Self-Determination theory questions were measured on a similar Likert

scale with two of the questions with 1=extremely likely and 7=extremely likely and one

question with 1=very committed and 5=not at all committed.

Findings

Research Question 1: What is the perceived competence of community health nurse

educators

regarding their disaster preparedness?

The 44 disaster familiarity questions (EPIQ) were measured on a Likert scale with

1=very familiar and 5= not familiar. The community health nurse educators’ perceived

competence in disaster preparedness was measured using the EPIQ mean score [n=122;

M=2.88; SD=1.026; Range=1-5]. With a median in the range of scores being a score of

2.89, the mean of 2.88 suggests that the overall perceived competence of community

health nurse educators relating to their familiarity with disasters is that they are somewhat

familiar. Figure 1 shows the disaster preparedness perceived competence of all

respondents.


Figure 1: Disaster Preparedness Perceived Competence

Research Question 2: Which of the variables-(individual differences); geographic

location, nursing background, age (generation), years of nursing, years as a community

health nurse educator, perceived importance of disaster content in courses, previous

disaster experience, and self-regulation most influence community health nurses


Community health nurse educators’ perceived competence in disasters was

measured using the 44-item EPIQ scale. Geographic location was included by using a

drop-down box that included all of the US states. A total of 36 states were represented in

the study. States that had the most survey responses were Texas (13.9%), Illinois (8.2%),

and New York (9.8%). An interesting point to note is that both Illinois and Texas

community health nurse educators reported less familiarity with disaster preparedness

than New York Community health nurse educators. An One-way ANOVA analysis was

applied to Texas, Illinois, and New York to compare and examine the significant


difference among the three states. There was no statistical significance between states

(F=.007, p=.993). Even though mean scores of states are close to each other, based on

the mean results of each of the three states (Illinois=3.05, New York= 3.00, Texas=3.03),

community health nurses in Texas are a little more familiar with the surveyed

components of disaster preparedness than Illinois. Figure 2 shows the disaster

preparedness mean according to the three highest responding states.

Figure 2: States with Highest Response Rate (TX, IL, NY)

Geographic location was also grouped into regions and an ANOVA analysis was

run to see how this would impact perceived competence in disaster nursing. The

breakdown for this analysis was 1=Midwest region, 2= Southern region, 3=Northeast

region, and 4= Western region. The Midwest region included; Illinois, Indiana, Iowa,

Kansas, Michigan, Minnesota, Missouri, Nebraska, Ohio, and Wisconsin. The Southern

region included; Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina,

South Carolina, Tennessee, Texas, and Virginia. The Northeast region included;


Connecticut, Maryland, Massachusetts, New Jersey, New York, Pennsylavania, and

Rhode Island.. The Western region included; Arizona, California, Colorado, Idaho, New

Mexico, Oregon, Utah, Washington, and Wyoming. The results were not statistically

significant (F=0.57, P=0.63). However, the data showed that the region with the highest

perceived competene in disaster nursing preparedness lived in the Western region. The

Western region accounted for the smallest number of responses, so that is important to

consider. See Table 2 for specific data.

Table 2

Geographic Regions

U.S. Region N Mean SD

Midwest 38 2.90 1.11

South 41 2.80 0.98

North 29 3.05 1.04

West 14 2.65 1.02

The nursing background of community health nurse educators was depicted on

the survey as a choice between the following specialty areas; ambulatory care,

community health, critical care, emergency services, medical-surgical, maternal-child,

operation room/PACU, pediatrics/neonatal, psych/mental health, or other. Community

health nurse educators were able to pick more than one background to reflect their

nursing experience. Table 3 shows the nursing backgrounds data.


Table 3

Nursing Backgrounds

Background Mean SD N

Ambulatory Care 3.02 .948 17

Community Health 2.86 1.01 107

Critical Care 2.81 1.13 13

Emergency Services 2.57 1.15 15

Medical-Surgical 2.82 1.01 21

Maternal-Child 2.96 1.03 20

Operation Room/PACU 2.64 1.02 6

Pediatrics/Neonatal 2.73 .80 10

Psych/MentalHealth 2.88 1.03 9

Other 2.84 1.05 30

Age was represented in the survey as a choice of generations; Millennials (born

between 1981-1996), Generation X (born between 1965-1980), Boomers (born between

1946-1964), and Silent (born between 1928-1945). A One-way ANOVA analysis was

conducted and showed no significant difference between generations and perceived

competence in disaster preparedness (F=.640, p=.591). Boomers reported greater

familiarity (mean=2.77, SD=1.066) with disaster preparedness than the other three

groups. Millennials reported familiarity with disaster preparedness (mean=2.98,

SD=1.099), which is the second most familiar of the groups. It is important to note the

number of participants in each generational group; Millennials n=9, Generation X n=38,

Boomers n=74, and Silent n=1. Due to the small sample in the Millennial and Silent


generations further, the next analysis was conducted without those two groups. An

independent t-test was run to see if there was significance between generation x and

boomers and there was no statistical significance (t=1.346, p=.314). Figure 3 shows the

mean disaster preparedness perceived competence among the generations.

Figure 3: Generation

The number of years each community health nurse educator had been a nurse was

also examined in relation to perceived competence of disaster preparedness. This was

represented on the survey as a choice in five year increments up to thirty; 0-5, 6-10, 11-

15, 16-20, 21-25, 26-30, and greater than 30. A One-way ANOVA was conducted to

complete this analysis. There was no statistical significance (F=1.022, p=.415) between

years of nursing between the groups and perceived competence in disaster preparedness.

The group that reported the most familiarity was those who had between 6-10 years of

nursing experience (n=5, mean=2.55) followed by those who had between 26-30 years of


nursing experience (n=23, mean=2.77). Figure 4 shows the disaster preparedness

perceived competence mean according to years as a nurse.

Figure 4: Years of Nursing Experience

Years of nursing experience was also grouped into 10 year increments and an

ANOVA analysis was run to see the impact on perceived competence in disaster nursing.

The breakdown for this analysis was 0-10 years, 11-20 years, 21-30 years, and greater

than 30 years. The results were not statistically significant (F=0.32 P=0.81). However,

the data showed that the lower the years of nursing experience, the lower the perceived

competence in disaster nursing preparedness. See Table 4 for more detailed data.


Table 4

Groups RN

Experience

Years RN Experience N Mean SD

0-10 years 8 3.18 1.26

11-20 years 15 2.87 0.98

20-30 years 36 2.79 1.04

Greater than 30 years 63 2.89 1.02

Community health nurse educators’ years of community health teaching

experience was included on the survey in five-year increments similar to the years of

nursing. This is a categorical variable and was categorized into five year increments

including; 0-5, 6-10, 11-15, 16-20, 21-25, 26-30, and the last catergory being greater than

30 years. A Oneway ANOVA was conducted to complete this analysis. There was no

statistical significance (p=.736) between years as a community health nurse educator and

perceived competence in disaster nursing preparedness. The group reporting the most

familiarity with disaster preparedness were those who had been community health nurse

educators for 21-25 years (n=11, mean=2.44) followed by those who had greater than 30

years’ experience as a community health educator (n=10, mean=2.73). Figure 5 shows

the disaster preparedness perceived competence mean according to years of experience as

a community health nurse educator.


Figure 5: Years as a Community Health Nurse Educator

Years of community health nurse educator (CHNE) experience were also grouped

into 10 year increments and an ANOVA analysis was run to see the impact on perceived

competence in disaster preparedness. The breakdown for this analysis was 0-10 years, 11-

20 years, 21-30 years, and greater than 30 years. The results were not statistically

significant (F=0.31, P=0.82). However, the data showed that the lower the years of

CHNE experience, the lower the perceived competence in disaster nursing preparedness.

See Table 5 for more detailed data.


Table 5

Groups CHE

Experience

Years CHE

Experience

N Mean SD

0-10 years 65 2.95 0.98

11-20 years 30 2.85 1.03

20-30 years 17 2.73 1.18

Greater than 30 years 10 2.73 1.15

Community health nurse educators were asked whether they felt it was important

to teach disaster preparedness in their courses with the response choices being yes,

maybe, and no. A Oneway ANOVA was conducted to complete this analysis. Since no

one answered no to this question the statistical analysis was conducted using only yes and

maybe responses. There was no statistical significance found between the perceived

importance of teaching disaster and the perceived competence of disaster preparedness

(F=.115, p=.735). The majority of the sample population responded that, yes, it is

important to teach disaster in their courses (n=118), with a small amount responong

maybe (n=4).


Figure 6: Importance of Including Disaster Content in Course

The sample population were asked if they had ever participated in a disaster and if

that influenced perceived competence in disaster preparedness. The choices were yes,

maybe, and no. 72 replied yes, 4 replied maybe, and 46 replied no. A Oneway ANOVA

was conducted to analyze the data. Having participated in a disaster previously was

significant in perceived competence in disaster preparedness between groups (F=6.62, p=

<.05). If community health nurse educators had actively participated in a major disaster

event in the past, they reported a greater perceived competence in disaster nursing

preparedness (p=.001).


Figure 7: Active Participation in Previous Disaster

The Self-Determination theory questions were measured using a Likert scale with

two of the questions with 1=extremely likely and 7=extremely likely and one question

with 1=very committed and 5=not at all committed. Self-regulation was incorporated into

the survey with three questions; How likely would you say you are to get involved and

prepared for disasters in your community, how committed are you to participating in

emergency preparedness measures in your community, and How likely are you to assume

the risk of involvement in a disaster situation? A oneway ANOVA analysis revealed that

Self-regulation and perceived competence in disaster preparedness are statistically

significant (p=.001). The higher the level of self-regulation the more familiar community

health nurse educators are with disaster preparedness.


Figure 8: Self-Regulation

Research Question 2, Sub Question 3: Is there a relationship between self-regulation

scores and perceived competence in disaster preparedness?

Self-regulation was examined using three questions in the survey; How likely

would you say you are to get involved and prepare for disasters in your community, How

committed are you to participating in emergency preparedness measures in your

community, and How likely are you to assume the risk of involvement in a disaster

situation (bio-terrorism event, pandemic etc.)? A one-way ANOVA was used to answer

this question. There was a statistically significant correlation between self-regulation

scores and perceived competence scores (F=5.38, p=<.001). The more familiar

community health nurse educators are with disaster preparedness, the higher their level of

self-regulation.


Research Question 2, Sub Question 4: is there a relationship between perceived

competence in disaster preparedness and the perceived importance of disaster nursing

education?

A one-way ANOVA was conducted to examine these variables. There was no

statistical correlation between a community health nurse educator’s perceived importance

of teaching disaster content in their community health course and their perceived

competence in disaster preparedness.

Research Question 3, Sub Question 5: Is there a relationship between perceived

competence in disaster preparedness and actively participating in a major disaster event?

A one-way ANOVA was conducted to examine these variables. There was a

statistical correlation between a community health nurse educator’s perceived

competence in disaster preparedness and a history of actively participating in a major

disaster event (F=6.63, P=<.05). There was a 0.67 higher score in perceived competence

in disaster preparedness of community health nurse educators who had previously

participated in a disaster.


Chapter 5: Summary and Conclusions

Summary

This descriptive correlational research study was the first to examine the

relationships between and among disaster preparedness perceived competence, self-

regulation and community health nurse educators. The sample population completed the

Emergency Preparedness Information Questionnaire (EPIQ) for measurement of disaster

preparedness familiarity (Wisiewski, Demmik-Champion, & Peltier, 2004), Self-

Regulation, and demographic data along with 2 researcher generated questions.

The aim of this study was to examine the disaster preparedness of community health

nurse educators. Concepts of the Self-Determination theory were used to guide this study.

The theory asserts that there is motivation behind choices that individuals make. People

become self-determined to make a change or learn something new when they feel

competent, connected, and autonomous; this study focused mainly on the feeling of

competence and how that influences the levels of familiarity of various components of

disaster preparedness. As mentioned in a research study conducted by Charney et. al

(2019), confidence and competence impact willingness to act in a disaster. This

information explained how concepts such as competence and self-regulalation can impact

a persons actions. The currrent study showed that when self-regulation was higher in a

community health nurse educator, and the community health nurse educator had previous

experience in a disaster their perceived comptenence in disaster preparedness was also

higher. Due to this, is reasonable to infer that when a community health nurse educator has

a high level of perceived competence in disaster preparedness, they too will be more likely

to act in a disaster situation.


Many of the demographic variables in this study were not statistically significant

including; geographic location, nursing background, age, years as a nurse, and years as a

community health nurse educator. This is reasonable considering what the literature has

shown to date regarding nurses and healthcare providers feeling unprepared for a disaster.

The study done by Charney et al. (2019), specifically showed that health care profession

students did not feel their programs of study included adequate disaster preparedness

content in the curricula. This leads back to the lack of cohesive and coordinated disaster

preparedness education in academic programs including programs of nursing. Differing

demographics do not appear to play a role in the perceived competence of nurses, of any

kind, in disaster preparedness and seems to be a nationwide problem.

Another important aspect of the study to note is that 121 respondants reported that

disater preparedness content is important to include in community health nursing

curriculum. This shows that along with recommendations from national nursing

organizations and leading public health experts, community health nurse educators realize

the need for inclusion of this essential content. As leaders in schools of nursing and

universities, community health educators are poised to demand change in this area of

nursing. As seen in the current COVID 19 pandemic, univerisites are realizing the need

for a stronger public health presence on campus. Better prepared community health nurse

educators can provide recommendations, advice, and expertise in this area, not only to

educate students, but to educate university leaders and aministrators in times of crisis.

The population sample for this study consisted of 122 people who met the inclusion

criteria for the study and who completed the survey. The sample included registered nurses

who were currently in the role of a community health nurse educator. The background of


the majority of the sample (n=107) included community health nursing although various

other nursing backgrounds were represented. Thirty-six states were represented in the

study. The majority of the sample (n=74) fell in the Boomer generation (born in 1946-

1964). The study was conducted via electronic survey made available by a link distributed

on the ACHNE listserv and then shared among the ACHNE members colleagues.

Participants were directed to the Qualtrics website that included the University of Missouri

St. Louis information affiliated with the researcher and the letter of participation.

Conclusions

Results of this study showed a statistical significance in community health nurse

educators mean perceived competence in disaster preparedness and previous disaster

experience (<.05). It is not surprising that educators who had actively participated in a

disaster previously would feel more competent in disaster preparedness and management.

This shows that the ability to practice during a disaster leads to nurses who are more

familiar with the various components of disaster work.

The research study also showed a positive correlation between perceived

competence in disaster preparedness and self-regulation (F=5.38, p=<.001). If a

community health nurse educator reported being more likely to get involved and prepared

for disasters, were committed to participating in emergency preparedness measures, and

were likely to assume the risk of involvement in a disaster situation; their familiarity with

components of disaster preparedness (perceived competence) was higher. Therefore, a

community health nurse educator with higher self-regulation would be expected to have

higher disaster preparedness perceived competence than those with low self-regulation.


Significant relationships were found between the independent variables of the

participants previous disaster experience and disaster preparedness and perceived

competence and self-regulation, supporting the self-determination theory. The empirical

evidence of this research study was congruent with Deci’s Self-determination theory that

states that motivation drives individuals to take on certain challenges and learning.

Although, disasters occur more today than they have previously, they are still not

something that healthcare providers think of as happening to them often. The need for

cohesive and coordinated disaster curriculum in schools of nursing has been expressed by

leading disaster nursing experts for years. This was most recently declared in the Johns

Hopkins Bloomberg School of Public Health Recommendations for Improving National

Nurse Preparedness for Pandemic Response: Early Lessons from COVID-19 (2020).

Starting by providing community health nurse educators with appropriate training and

educational tools can help fill the gap in their knowledge. Only then can educators

adequately provide disaster preparedness content and hands on learning experiences that

will allow nursing students to gain experience and increase their competence in disaster

preparedness.

Limitations

Limitations related to many aspects of research studies such as; design, sample, and

instrumentation should be considered when interpreting data. Inclusion criteria limited

participation in the is research study to community health nurse educators only. As this

study limited participation to nurses who were from a particular professional association

or the colleagues of members of that association, the sample may not be reflective of

community health nurse educators in states without participation and other associations.


Additionally, participants were required to be community health educators further limiting

eligibility for participation in the study and enhancing probability of not being

homogenous. A future study could focus on community health nurse who do not

necessarily teach the content.

A second limitation is that this research was conduction at the beginning and middle

of worldwide pandemic. The sample population of this research study were busy

reformatting classes, investigating new clinical experiences, and working on task

forces/pandemic planning committees. This particular group of nurses were potentially

strapped for time as other educators were but more so because of the specialty area under

which disaster preparedness content falls. Schools of nursing in many states were moved

to online and typical practicum experiences were eliminated due to the pandemic. Many

nurses were also on COVD 19 overload. Dealing with it in the workplace and classrooms

might have made nurses less likely to want to respond to a disaster preparedness survey.

The other limitation related to conducting this research during a pandemic, is that those

who answered the survey during the midst of the pandemic (the second survey) might

report better than usual scores due to recent trainings/webinars required during the

pandemic. Even just reading the news reports and listening to public health professionals

might have swayed respondents to feel better prepared than they actually were.

A third limitation of this study was the use of the self-report instrument. Self-report

instruments are based on participant perception of their knowledge and understanding of

the consent and questions. A participant’s perception of knowledge may not reflect actual

knowledge and misunderstanding of directions and questions by participants could result

in incorrect responses or incomplete surveys leading to inaccurate results. The sample of


this study was accessed via ACHNE, a professional organization. Participants belonging

to a prof org may have been hesitant to report their lack of familiarity to some of the disaster

components for fear that they were things they felt they should know.

A fourth limitation of the study is that greater than half (n=72) of the sample

reported having previous experience working in disasters. Using a sample with a greater

number of nurses without previous disaster experience may have yielded different results.

Recommendations for Future Research

Continued research on the disaster preparedness competence of community nurse

educators is recommended. This study found a positive significant relationship between

previous disaster experience and perceived competence in disaster preparedness and self-

regulation and perceived competence in disaster preparedness. Future research should

explore the relationships between disaster competence and other concepts related to

community health courses to gain a better understanding how to further improve disaster

preparedness competence among nurses.

The limitations of this study can help to guide future studies. A study that is sent to

all schools/colleges of nursing that include a community health nursing course would be

helpful. Not focusing solely on a community health nursing association would broaden the

responses. Replicating this study when there is not a current pandemic may show a more

accurate depiction of the familiarity of community health nurse educators in disaster

preparedness. An exam that showed the true preparedness of individuals might be

beneficial as opposed to the perceived competence (familiarity) of disaster preparedness.

Lastly, surveying nurses who have never participated in a disaster previously might provide

more information on nurses without a background in disaster preparedness.


A plan is in the works to conduct a secondary study from this data to examine the

differences between the first survey reponses (the beginning of the pandemic) and the

second survey responses (the later stages of the pandemic). It will be interesting to see if

there were differences between the perceived competence of community health nurse

educators at those two points of the pandemic. Since the survey covers aspects of

communicable diseases this study would be relevant to COVID research, as well.

Implications

The results of the study lead to several key implications for policy and practice.

This research further explains the extent of a lack of disaster preparedness content in

nursing programs. With the knowledge from previous research studies finding that nursing

students feel unprepared for a disaster, this study takes things a step further by examining

the preparedness of the educators who teach the content. Trainings and education are

needed for community health nurse educators along with adequate disaster competencies

to incorporate into their community health course. Community health nurse educators also

should have a seat at the table to discuss how this curriculm should be taught.

The relationships between disaster preparedness competence and previous disaster

experience suggests that education and experiential learning may be a good way to teach

disaster preparedness. Educators who have experienced a disaster themselves, may be the

most competent to teach the content. Those who are more likely to get involved and prepare

for disasters, are committed to participating in emergency preparedness measures, and are

more likely to assume the risk of involvement in a disaster situation will also be more

familiar with disaster preparedness.


The study showed that even community health nurse educators, who teach disaster content,

do not feel extremely familiar with many aspects of disaster preparedness. These results

tell us that the education that is occurring in nursing courses and in the field of nursing, are

not adequate.

Practice and Education

Practice and education policies are key in making change to any academic program.

The recent guidelines set forth by the Johns Hopkins Bloomberg School of Public Health

make recoemmendations that are aimed at several key stakeholders, one being institutional

of higher education and professional nursing education organizations to prepare nurses for

emergency preparedness (Johns Hopkins, 2020).

Short term recommendations include:

1. Schools of nursing should develop and implement robust metrics for evaluating

nurse preparedness and apply them across academic and lifelong learning

programming.

2. State boards of nursing should establish a requirement for continuing education for

public health emergency preparedness and response.

3. Schools of nursing, in collaboration with state boards of nursing, should develop a

plan for continuity of clinical education during public health emergencies to ensure

the integrity of the nursing workforce.

Long-term recommendations include:

1. American Association of Colleges of Nursing should release revised curricular

Essentials and a tool kit for schools and universities to facilitate the inclusion of


emergency preparedness and response content across all baccalaureate and

graduate academic programs.

2. The Accreditation Commission for Education in Nursing and the Nursing

Commission for Nursing Educatin Accreditation, the 3 nursing accrediting bodies,

should require the inclusion of teaching and simulation on emergency preparedness

and response.

3. Academic nursing should formulate a proactive response to the changing infectious

disease landscape by offering certificates and digital badges in emergency

preparedness and response.

Along with these academic requirements created by leading disaster nursing experts in

coordination with Johns Hopkins, proper training and professional development should be

provided for community health nurse educators. In the spirit of lifelong learning, these

trainings should be offered yearly and as often as changes to best practice occur.

Community health nurse educators are on the frontlines of healthcare’s response in

a disaster. It is vital that university administration, curriculum developers, state boards of

nursing and faculty members understand the importance of disaster preparedness

competence and promote the education and training of this population of nurses as well as

its importance to a well-rounded nursing curriculum. This study found support for Deci’s

self-determination theory and represents an opportunity to include this critical content in

all programs. Community health nurse educators can stress the importance of the nurse’s

role in disaster preparedness to administrators and state boards of nursing and provide

students with the self-determination to take the risks involved in learning and acting in a

disaster. None of this can happen, though, until we make sure that our disaster preparedness


leaders, community health nurse educators, have the preparedness training they need to be

true content experts. Only then, can we prepare our nursing students for the next disaster

that is sure to come.


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